Masculinizing surgery encompasses procedures that alter your appearance to promote the matching of your gender identity and body (gender congruence). Masculinizing surgery includes many options, such as "top" surgery to remove your breasts and create a more male-contoured chest and "bottom" surgery to increase the length of the clitoris (metoidioplasty), create a penis (phalloplasty) or create a scrotum (scrotoplasty).
People who seek masculinizing surgery, also called gender-affirming surgery, often do so as a step in the process of treating discomfort or distress because their gender identity differs from their sex assigned at birth or sex-related physical characteristics (gender dysphoria).
Masculinizing surgery isn't for all transgender men. These surgeries can be expensive, carry risks and complications, and involve follow-up medical care and procedures. Prior to some types of surgery, you'll be required to get recommendations from behavioral health providers, live as a male and be on masculinizing hormone therapy for a specific period of time. Certain surgeries will alter your fertility and your sexual sensations, in addition to how you feel about your body.
Your doctor, as well as people who have had these surgeries, can help you weigh the risks and benefits.
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Why it's done
People who seek masculinizing surgery experience discomfort or distress because their gender identity differs from their sex assigned at birth or sex-related physical characteristics (gender dysphoria).
For some transgender men, masculinizing surgery is a natural step — and important to their sense of self. However, many don't choose to have surgery. Transgender people relate to their bodies differently and need to make individual choices that best suit their needs.
Masculinizing surgeries are typically deferred until adulthood. Options include:
- Surgical removal of your breast tissue (top surgery for transgender men)
- Surgical placement of implants to create the appearance of a defined male chest (pectoral implants)
- Various aesthetic procedures, such as a surgical procedure that uses a suction technique to remove fat from specific areas of the body (liposuction) or fat grafting
- Genital surgery to remove your uterus (hysterectomy), or uterus and cervix (total hysterectomy), or fallopian tubes and ovaries (salpingo-oophorectomy)
- Surgery to remove all or part of your vagina (vaginectomy), create a scrotum (scrotoplasty), place testicular prostheses, increase the length of the clitoris (metoidioplasty) or create a penis (phalloplasty)
Masculinizing surgery isn't for all trans men. Your doctor might recommend against these surgeries if you have:
- Uncontrolled behavioral health conditions
- Uncontrolled significant health conditions
- Any condition that limits your ability to give your informed consent
Like any other type of major surgery, many types of masculinizing surgery pose a risk of bleeding, infection and an adverse reaction to anesthesia. Other complications might include:
- Delayed wound healing
- Fluid accumulation beneath the skin (seroma)
- A solid swelling of clotted blood within your tissues (hematoma)
- Changes in skin sensation such as persistent pain, tingling, reduced sensation or numbness
- Damaged or dead body tissue (tissue necrosis), such as in the nipple and in the surgically created penis (neophallus)
- A blood clot in a deep vein (deep vein thrombosis) or a blood clot in a lung (pulmonary embolism)
- An abnormal connection between two body parts (fistula), such as in the urinary tract
- Urinary problems, such as incontinence
- Pelvic floor dysfunction
- Permanent scarring
- Loss of sexual pleasure and functioning
- Worsening of an underlying behavioral health concern
Certain types of masculinizing surgery can harm or end your fertility. If you want to have biological children and you're having surgery that involves your reproductive organs, talk to your doctor about freezing your eggs (mature oocyte cryopreservation) or embryos (embryo cryopreservation) before moving forward. Another option involves having ovarian tissue surgically removed, frozen and later thawed and reimplanted (ovarian tissue cryopreservation).
Keep in mind that egg freezing has multiple steps — ovulation induction, egg retrieval and freezing. If you want to freeze embryos, you'll need to go through the additional step of having your eggs fertilized before they are frozen.
How you prepare
Before masculinizing surgery, you'll meet with your surgeon. Consult a surgeon who is board certified and experienced in the procedures you desire. Your surgeon will describe your options and potential results. The surgeon will provide information on the anesthesia, the location of the operation and the kind of follow-up procedures that you might need. Follow your doctor's specific instructions on preparing for your procedures, including guidelines on eating and drinking, adjusting current medications, and quitting smoking.
Although giving your informed consent after discussing the procedure’s risks and benefits is an acceptable standard of care, most surgeons will require you to meet certain criteria before having a masculinizing surgery. To start, your surgeon will evaluate your health to rule out or address any medical conditions that might affect or contraindicate treatment. The evaluation might include:
- A review of your personal and family medical history
- A physical exam, including an assessment of your internal reproductive organs
- Lab tests measuring your lipids, blood sugar, blood count, liver enzymes and electrolytes
- A review of your immunizations
- Age- and sex-appropriate screenings
- Identification and management of tobacco use, drug abuse, alcohol abuse, HIV and other sexually transmitted infections
- Discussion about contraception and future fertility
A behavioral health evaluation by a provider with expertise in transgender health is also required. The evaluation might assess:
- Your gender identity and gender dysphoria
- The impact of your gender identity at work, school, home and social environments, including issues related to discrimination, relationship abuse and minority stress
- Mood or other mental health concerns
- Sexual health concerns
- Risk-taking behaviors, including substance use and use of nonmedical-grade silicone injections or unapproved hormone therapy or supplements
- Protective factors such as social support from family, friends and peers
- Your goals, risks and expectations of treatment and your future care plans
In addition, before having non-genital masculinizing surgery, you'll be required to have one letter of support from a behavioral health provider with expertise in transgender health. The letter must confirm that you meet the World Professional Association of Transgender Health (WPATH) standards of care criteria for surgery, including:
- Having the ability to make fully informed decisions and to consent to treatment
- Be managing any major medical or mental health problems
Before having genital surgery, you'll be required to obtain two letters of support, each from a behavioral health provider with expertise in transgender health. The letters must confirm that you meet the WPATH standards of care criteria, including:
- Undergoing hormone therapy as appropriate to your gender goals for at least 12 months, unless you have a medical contraindication or you're otherwise unable or unwilling to take hormones
- Living in a gender role that matches your gender identity for at least 12 continuous months
Since masculinizing surgery might cause irreversible physical changes, you must give informed consent after thoroughly discussing:
- Risks and benefits
- Alternatives to surgery
- Expectations and goals
- Social and legal implications
- Potential complications
- Impact on sexual function and fertility
Health insurance coverage for masculinizing surgical procedures is variable.
You might also consider talking to others who've had masculinizing surgery. They can help you shape your expectations of what can be achieved and what personal and social problems you might experience during treatment.
What you can expect
Top surgery for transgender men or masculinizing chest surgery involves the removal of your breast tissue (subcutaneous mastectomy). If your breast size is small, you might be able to have surgery that spares your skin, nipple and areola (nipple-sparing subcutaneous mastectomy). This procedure minimizes scarring, has a faster healing time and usually preserves sensation in the nipples. If you have larger breasts, you might need to have your nipples and areolas taken off, resized and grafted back into position. This causes more scarring and loss of sensation to the nipple.
If you are a carrier of genetic mutations that increase your risk of breast cancer, you might also choose to have your nipples and areolas completely removed and subsequent surgery or tattooing to recreate their appearance.
After surgery, you might need to stay in the hospital overnight. You'll likely have one or two small plastic tubes placed where your breasts were removed to drain any fluids that accumulate after surgery. You might not be able to bear weight on your upper body for six weeks.
Some breast tissue will likely remain regardless of the surgical technique. As a result, your doctor will talk to you about the need for continuing routine breast cancer screening.
Metoidioplasty is a procedure to increase the length of the clitoris without grafting tissue from other parts of the body. During surgery, the clitoris is freed from its attachment to your labia minora and a suspensory ligament. Your surgeon can also extend your urethra through your released clitoris using a graft typically taken from the lining of your mouth (urethral hookup). This will make standing urination possible.
This procedure typically results in a penis with an unstimulated length of between 1 and 3 inches (3 and 8 centimeters). Typically, full sensation and orgasmic function are retained.
It isn't necessary to have your vagina closed or removed before having metoidioplasty. Penetration and pap tests might not be possible afterward. As a result, your surgeon might recommend removing your uterus, cervix and ovaries during metoidioplasty.
After metoidioplasty, you'll have a tube (catheter) placed in your urethra to collect urine. Recovery might take up to two weeks.
Phalloplasty, the surgical creation of a penis, involves multiple procedures. During phalloplasty, large amounts of donor skin will be taken from other areas of your body, such as your forearm, calf or lower abdomen. This can cause significant scarring. The skin will be rolled into the shape of a penis and anchored into position above your clitoris. You might also have:
- Urethral lengthening to allow for urination through your penis
- Grafting of nerves and blood vessels to provide sensation in your penis
- A procedure to sculpt the head of your penis (glansoplasty)
- Medical tattooing to create a distinct difference between the head and shaft of your penis
After phalloplasty, you'll have a tube (catheter) placed in your urethra to collect urine. You'll likely need to stay in the hospital for a few days. Phalloplasty carries a high rate of complications and might require many follow-up surgeries. Depending on the procedures done, recovery might take up to 12 weeks. Your new penis will not be able to become erect with sexual stimulation. A penile implant will be needed to allow penetrative sexual intercourse.
Scrotoplasty is the surgical creation of a scrotum. During scrotoplasty, egg-shaped silicone testicular implants are inserted into your labia. To prepare for the procedure, you'll have expanders placed under the skin in your labia. The expanders will be gradually filled with saline through an external port over a period of months. When your skin has been expanded enough, your surgeon will insert the implants.
Some people find the implants uncomfortable. It's possible for the implants to wear through surrounding tissue or become infected.
Research suggests that gender-confirming surgery can have a positive impact on your well-being and sexual function.
Long-term postoperative care and follow-up after surgical treatment for gender dysphoria also have been linked with good outcomes. Before you have surgery, talk to your surgeon, hormone-prescribing doctor — if you're taking hormones — and your behavioral health provider about what ongoing treatment you'll need.
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